A nurse, in an Ohio Hospital, accidentally discarded a kidney that was awaiting a transplant and had been provided by a living donor. The nurse had been on break, had been replaced by a different nurse, and was therefore unaware the kidney was submerged in an ice filled sludge. She purposely disposed of the contents into a disposal hopper thinking the kidney was still in the operating room because “that’s what usually happens.”
The hospital suspended the two nurses after the incident; one was later fired, and the other resigned. Furthermore, a surgeon was stripped of his title as director of some surgical services. What a tragedy on many levels.
The nurse who discarded the kidney had walked past a doctor and other nurses carrying the container. Should someone have noticed? Should someone have said something? How was she to know? She was fired! Does that make sense?
In the light of our typical industrial age model of management that focuses on holding people accountable for results it makes total sense. Why? Because, someone must be at fault! That’s the philosophy with which we were raised. That’s the philosophy that dominates our schools and our organizations, i.e. someone must be held accountable for the results.
In 1950 Dr. W. Edwards Deming explained his philosophy of systems thinking to the Japanese leadership. The Japanese proceeded to implement Deming’s philosophy of Profound Knowledge. By the late 1960’s Japan was dominating the manufacturing of electronics including televisions, radios, and stereos. By the end of the 1970’s the gap in quality between Japan and the USA was reaching a crisis. The philosophy of focusing on the improvement of the system was winning the competitive edge. Costs were lower and quality was higher. The age of blaming people for mistakes was dead. At least it was in Japan. Unfortunately it is still very much alive today in America.
Today we still tend to blame people for mistakes. Unfortunately, according to Dr. Deming’s philosophy probably 94% of all mistakes come from the system and processes and only 6% from the people. There were probably a dozen or more hand-offs that occurred in that operating room between the surgery preparation time and the time the nurse returned from her break. Each of those hand-offs was an opportunity to have good quality or poor quality. Information about the location of the kidney was a hand-off. What to do with the slush was a hand-off. Each of those hand-offs was a process that could be improved. To blame her does nothing to improve those hand-offs and therefore, nothing to prevent a re-occurrence.
Today our children are failing to learn reading and math skills at their respective grade levels, yet we continue to embrace standardized testing and performance evaluations for teachers. We continue to attempt to improve the individuals by judging, grading, blaming, and firing them. We fail to fully recognize that our system of grading students destroys their passion for learning and steals their willingness to take responsibility for their own learning progress. We continue with the same flawed processes and hand-offs that make up the entire dysfunctional system. We blame and then expect different results.
If we fired every nurse and every teacher in the country and replaced them all with highly trained substitutes would we improve anything? Couldn’t we expect that the same number of students would fail and the same number of kidneys would be discarded? Unless we embrace a systems view of the world and stop blaming we will continue to see these tragedies. If blame is alive, improvement and systems thinking will take a back seat.